BLUNT ABDOMINAL TRAUMA AND DUODENUM RUPTURE IN A PATIENT WITH SEVERE HAEMOPHILIA B

84

Journal of Experimental Medical & Surgical Research

Cercetãri Experimentale & Medico-Chirurgicale

Year XVII · Nr.2/2010 · Pag. 84 - 91E x p e r i m e n t a l

M e d i c a l S u r g i c a l

R E S E A R C H

J O U R N A L o f

Correspondence to: Narcis F. Tepeneu, Assistant Professor, Pediatric Surgery and Orthopaedics Clinic , Emergency Children’s Hospital ‘’Louis Turcanu ‘’ , I. Nemoianu Street No. 2, Timisoara, Tel .+40-256-203373, E-mail: nftepeneu@yahoo.com

SUMMARY: We present the case of a 4 year old patient with severe haemophilia B, admitted as a emergencycase in the Pediatric Surgery and Orthopaedics Clinic Timisoara, by transfer from the countyhospital Târgu-Mureº, with a politrauma after a domestic accident. The onset was acute, after thepatient stumbled and hit himself on the edge of a metallic object. On admission he presented aworse general status, pale tegument, dry mucous membranes, a temperature of 37,8 ºC, weakpulse of 120 b/min, blood pressure of 86/40 mm Hg. Abdominal examination showed a slightlydistended abdomen, which did not move with respiration and presented tenderness, guarding inthe epigastric area and right upper quadrant and signs of peritoneal irritation. After a short period in which the patient was stabilised and paraclinical investigations wereconducted, which determined hypovolemic shock and raised the suspicion of massivehemoperitoneum, a surgical intervention was performed. Intraoperative findings were a widepost-traumatic incomplete rupture of dudenum IV with massive hemoperitoneum, extensiveduodeno-jejunal intramural haematoma, pancreatic contusion. A intestinal resection of the IVthpart of the duodenum and of the first jejunal loop was performed, followed by a termino-terminalduodeno-jejunal anastomosis, drainage of the the hemoperitoneum and peritoneal drainage.Substitution with FIX concentrate was initiated , initially as a continous intravenous infusion,afterwards in bolus injections. Local and general evolution was favorable, without complicationsand the patient was released from the hospital on the 12th postoperative day.

Key Words:haemophilia B , politrauma, duodenal rupture, intestinal resection

TRAUMATISM ABDOMINAL CU RUPTURÃ DE DUODEN ÎNTR-UN CAZ DE HEMOFILIE BFORMÃ SEVERÃ

Rezumat: Se prezintã cazul unui pacient în vârstã de 4 ani, cunoscut cu hemofile B formã severã, internat deurgenþã în Clinica de Chirurgie ºi Ortopedie Pediatricã Timiºoara, prin transfer de la SpitalulJudeþean Târgu-Mureº, cu un politraumatism prin accident casnic. Debutul a fost brusc, în urmãcu aproximativ 24 de ore, când pacientul s-a împiedicat, a cãzut ºi s-a lovit de marginea unui obiect metalic. La internare a prezentat o stare generalã influenþatã, cu tegumente palide, mucoaseuscate, temperatura 37,8 ºC , puls filiform,120 bãtãi/min, TA= 86/40 mm Hg. La examenul locals-a constatat: Abdomen moderat destins de volum, nu participã la miºcãrile respiratorii, durerosspontan ºi la palpare în epigastru ºi hipocondrul drept, cu contracturã muscularã generalizatã ºisemne de iritatie peritonealã. Dupã o scurtã reechilibrare a pacientului ºi efectuarea investigaþiilor paraclinice, care au decelatºoc hipovolemic ºi au ridicat suspiciunea unui hemoperitoneu masiv , s-a intervenit chirurgical ºis-a decelat intraoperator o rupturã post-traumaticã incompletã întinsã la nivelul duodenului IV cuhemoperitoneu masiv, hematom masiv difuz duodeno-jejunal, hematom mezenteric, contuziepancreaticã. S-a practicat enterectomie segmentarã cu rezecþia porþiunii IV a duodenului ºi aprimei anse jejunale ºi duodeno-jejunoanastomozã termino-terminalã, evacuareahemoperitoneului ºi drenaj peritoneal. S-a iniþiat substituþie cu concentrat de FIX, iniþial în perfuzie endovenoasã continuuã, ulterior în bolus. Evoluþia locala ºi generalã a pacientului a fostfavorabilã, fãrã apariþia complicaþiilor ºi externare în ziua 12 postoperator.

N. F. Þepeneu1, ªt. Lazea1

Received for publication:

21.02.2010

Revised: 14.03.2010

1. - Pediatric Surgery and Orthopaedics Clinic , Emergency Children’s Hospital ‘’Louis Turcanu ‘’

CASE REPORT

A 4 year old patient with severe haemophilia B was

admitted as a emergency in the Pediatric Surgery and

Orthopaedics Clinic Timisoara, by transfer from the

county hospital Târgu-Mureº, with a politrauma after a

domestic accident. The onset was acute, after the patient

stumbled and hit himself on the edge of a metallic object.

Approximately 6 hours after the incident, because of the

fact that the child presented progressive epigastric and

right hypochondrial pain, nausea, bilious vomiting,

constipation and failure to pass flatus, the parents took

him to the hospital in Odorheiu Secuiesc, from where he

was redirected to the emergency county hospital

Targu-Mures. Because the hospital in Targu-Mures did

not have specific substitution for Haemophilia B and

because there was a suspicion of acute abdomen, the

child was transferred to Timisoara.

On admission he presented a worse general status,

pale tegument, dry mucous membranes, a temperature

of 37,8 ºC, weak pulse of 120 b/min, blood pressure of

86/40 mm Hg and a frontal haematoma. Abdominal

examination showed a slightly distended abdomen,

which did not move with respiration and presented

tenderness, guarding in the epigastric area and right

upper quadrant and signs of peritoneal irritation.

An erect abdominal X-ray on day 1 showed a single

air-fluid level in a dilated stomach and a gasless lower

abdomen.There was also a suspicion of a lack of

continuity of the duodenal wall with duodenal

edema/haematoma. Thoracic X-ray showed a slightly

dilated pulmonary hilum with a slightly enlarged heart

(Fig.1).The head X-ray was normal.

The emergency abdominal ultrasound showed a well

defined hyper echoic mass measuring 58x48x56 mm

adjacent to the gall bladder and to the right of the lower

part of the stomach. The liver, spleen, pancreas and

kidneys appeared normal.There was also a diffuse hyper

echoic mass in the Douglas space.

Other paraclinical findings were a hemoglobin level of

6 g%, with only 2.110.000 erythrocytes/mm3, raised

leucocytes (12400/mm3),low level of trombocytes

(78.000/mm3 ), raised amylasemia , hypoproteinemia,

normal prothrombin time(PT) and prolonged partial

thromboplastin time(PTT) of 64 seconds(control 30

seconds), hyponatremia , CRP level of 18,4 mg/l, normal

transaminases level.

The child received intravenous rehydration and

transfusion with 1 unit of whole blood and 1 unit of fresh

frozen plasma. Specific substitution with FIX

concentrates was started immediately, initially with a a

intravenous bolus of 70 UI/Kg and afterwards as a as a

continuous intravenous infusion with 4 UI/kg/h .

Nasogastric decompression and intravenous

antibiotherapy with Tienam was also started.

Because of the fact that the general status worsened

and the child developed progressive signs of peritonism

and abdominal distension and also because of the fact

that he was hemodinamically unstable, a surgical

intervention was carried out.

A median laparatomy was performed. After entering

the peritoneal cavity a massive hemoperitoneum of

approximately 500 ml was evacuated. The intraoperative

findings were a wide post-traumatic incomplete rupture

of dudenum IV , continued to the jejunum over a length of

approximately 20 cm, extensive duodeno-jejunal

intramural haematoma, pancreatic body contusion and

hematoma into the root of the mesentery.

After the American Association for the Surgery of

Trauma (AAST) classification system the duodenal

trauma was classified grade III (Table 1) and the

pancreatic lesion as grade I (Table 2).

A intestinal resection of the fourth part of the

duodenum and of the first jejunal loop was performed,

followed by a termino-terminal duodeno-jejunal

anastomosis, drainage of the the hemoperitoneum and

peritoneal drainage.

85

Fig.1 Patient for years: thoracic X-ray

Substitution with FIX concentrates was given as

continuous intravenous infusion according to the

recomandations of the World Federation of Haemophilia,

initially at a level of 4 UI/kg/h for the first 24 hours,

afterwards 3UI/kg/h and then 2,5UI/kg/h from the 2nd

postoperative day until the 8th postoperative day

(Table 3), when again bolus injections were started at a

dosage of 20 UI/Kg/dosis at 12 hours interval until the

12th postoperative day. Postoperative the patient

received a unit of erythrocyte mass concentrate.

Antibiotherapy was continued for 10 days.

Local and general evolution was favorable, without

complications and the patient was discharged from the

hospital on the 12th postoperative day on a normal diet,

with no abdominal pain, tenderness or masses and

normal bowel habit. He has remained well at follow up.

DISCUSSION

Blunt pancreatic and duodenal trauma is uncommon,

amounting to less than 2% of all abdominal injuries. These

injuries often occur during traffic accidents as a result of

the direct impact on the upper abdomen of the steering

wheel or the handlebars.

The duodenum and pancreas can be injured

simultaneously; isolated injuries are rare (<30%).

Coexisting injuries are common (50%–98%), with an

average of three to four for each patient. Identification of

a blunt injury of the duodenum and pancreas may be

difficult because imaging findings are often subtle.

Delays in diagnosis, incorrect classification of the injury,

or delays in treatment can increase the morbidity and

mortality considerably.(1,2,3,4)The morbidity and

mortality associated with a trauma to the duodenum and

86

GRADE INJURY DESCRIPTION

I Hematoma, laceration Involvement of a single portion of the duodenum

II Hematoma, lacerationInvolvement of more than one portion, disruption of<50% of the circumference

III LacerationDisruption of 50%–75% of the circumference of D2;disruption of 50%–100% of the circumference of D1, D3, and D4

IV LacerationDisruption of >75% of the circumference of D2 orinvolvement of the ampulla or distal common bile duct

V Laceration, vascular injuryMassive disruption of the duodenopancreatic complex or devascularization of the duodenum

Note.—Major variables are involvement of one or more parts of the organ, type of injury (hematoma, laceration, or disruption), and

involvement of the ampulla and bile duct. The duodenum is divided into the duodenal bulb (D1), descending part (D2), transverse part

(D3), and ascending part (D4).

Table 1. Scoring Duodenal Injury

GRADE INJURY DESCRIPTION

IHematoma

Laceration

Minor contusion without duct injury

Superficial laceration without duct injury

IIHematoma

Laceration

Major contusion without duct injury

Major laceration without duct injury or tissue loss

III Laceration Distal transection or parenchymal injury with duct injury

IV LacerationProximal transection or parenchymal injury involving the ampullaor bile duct

V Disruption Massive disruption of the pancreatic head

Note.—Major variables are site (proximal vs distal), type of injury (hematoma, laceration, or transection), and state of the mainpancreatic duct. The AAST system differentiates between hematomas, contusions, lacerations with and without ductal involvement,

and complete organ disruption and considers the site of the injuries.

Table 2. Scoring Pancreatic Injury

pancreas are remarkably high. Mortality for pancreatic

injuries ranges from 9% to 34%; for duodenal injuries it

ranges from 6% to 29%. However, only 5% of the

pancreatic injuries and 30% of the duodenal injuries are

directly related to the fatal outcome. The variability in

morbidity and mortality is caused by several factors: the

presence of coexisting injuries, the mechanism of injury,

the time to diagnosis, the presence or absence of major

ductal injury, and duodenal perforation, which are

considered to be predictors of outcome.(5) The

probability of complications after duodenal or pancreatic

trauma ranges between 30% and 60% and in many cases

is the result of missed findings or diagnostic delays or

both. Delayed diagnoses and therapeutic interventions

often result in a difficult clinical course with a dubious

outcome. However, within the first 48 hours after

pancreatic injury, most patients succumb to hemorrhage

from splenic, hepatic, or vascular injuries.(3,5,6) Organ

injuries most commonly associated with pancreatic

trauma are hepatic (46.8% of cases), gastric (42.3%),

major vascular (41.3%), splenic (28.0%), renal (23.4%),

and duodenal (19.3%). The high energy transfer and the

proximity of the duodenum and pancreas to other vital

structures result in few isolated injuries.(3,5,6)

Coexisting injuries and fatal hemorrhage are responsible

for early deaths, while infections and multiorgan failure

cause most late ones.

Approximately one-third of the patients who survive

the first 48 hours develop complications related to their

pancreatic or duodenal injury. Common complications of

duodenal and pancreatic injuries include pancreatitis,

pseudocysts, fistulas, intraabdominal abscesses,

pneumonia, and anastomotic breakdown, and these are

related to the development of multiorgan failure and

septicemia.7,8, About 37% of late deaths are primarily

attributable to the injury itself and usually occur within

1–3 weeks of the injury or later.7,8,9 The time between

the injury and the diagnosis and definitive treatment is an

important factor in the development of complications and

their resulting mortality. When a definitive diagnosis is

delayed for more than 24 hours, up to 40% of patients are

at risk of death, as opposed to 11% of those patients

operated on within 24 hours. Another study has

confirmed these observations and notes that all of the

deaths directly related to duodenal or pancreatic injuries

occurred in cases in which diagnosis was

delayed.(10,11,12) Today, computed tomography (CT)

provides the safest and most comprehensive means of

diagnosis of duodenal and pancreatic injury in

hemodynamically stable patients.(13,14,15,16,17,18)

In general, their retroperitoneal location usually

protects the pancreas and duodenum from many

instances of minor abdominal trauma. Pancreatic and

duodenal injuries usually result only from severe

anteroposterior compression trauma against the spinal

column, mostly in connection with seat belt injuries,

deceleration trauma, and handlebar compression trauma.

Less common mechanisms of injury are sports injuries,

falls, and blows to the upper abdomen. Most blunt

pancreatic injuries (>65%) occur in the pancreatic body.

Those to the pancreatic tail and head are less common.

Blunt pancreatic trauma is more common among

children because of more intense transmission of energy

and less protection by a usually thinner layer of

peripancreatic fat. Force exerted on the right upper

quadrant can affect the pancreatic head or uncinate

process and cause injuries in the descending and

transverse portions of the duodenum. Coexisting injuries

can affect the liver, bile duct, gallbladder, right kidney,

and ascending colon. Force exerted on the left upper

quadrant results mainly in injuries left of the superior

mesenteric artery, to the pancreatic body or tail as well

as to the transverse and ascending portions of the

duodenum. Coexisting injuries can affect the spleen,

stomach, and left kidney.(1,3,20,21)

Clinical symptoms comprise a triad of leukocytosis,

raised serum amylase activity, which can be absent in

the first few days, and upper abdominal pain.

However, clinical signs are often vague and

nonspecific, sometimes even nonexistent. Therefore,

87

Hemophilia B Dosage Day

Preoperative40 IU/Kg

Bolus1

Postoperative 3-5 IU/Kg/h* 1

2-3 IU/Kg/h* 2-10

*The diluted bottle of FIX concentrate will be administred during a period of 6-8 hours

Table 3 – FIX administration regimen according to the World Federation of Haemophilia(WFH

major pancreatic injuries can occur with initially minimal

epigastric symptoms. Blunt pancreatic and duodenal

trauma can occur in patients with multiple trauma, and

many will have undergone intubation or received

sedatives and therefore

cannot provide reliable data for evaluation. To obtain a

reliable history in an emergency situation is difficult and

in many cases barely feasible. Injuries to the pancreas

and duodenum are also likely to be masked by most

typical coexisting injuries.(1,3,15,22)

The most common test is the analysis of serum

amylase activity. This can be raised, although in up to

40% of cases it remains normal for 2–48 hours after an

injury. Repeated testing is recommended, but results do

not indicate the severity of the injury. Instead,

continuously increased activity or increasing activity are

more reliable and have been used for follow-up studies

and to monitor the extent of an established pancreatic

injury. In addition, the latter features can indicate the

need for intervention or operation. Increased activity in

general is not specific, as it may occur with salivary

gland, facial, small bowel, or hepatic trauma or if the

patient is intoxicated.

Serum lipase activity is also not specific for pancreatic

injury. It has been used in children with pancreatic

trauma but is not considered cost-effective.

Trypsinogen-activating peptide has not been fully

evaluated so far, and no reliable data are available.

(15,23,24,25)

CT is an essential means of diagnosing traumatic

lesions of the duodenum. Experience has shown that

nonperforating duodenal conditions can be missed, as

only free air or oral contrast medium extravasation are

specific signs of duodenal perforation. (26,27 )

Duodenal injuries are the result of penetrating or blunt

trauma. It is essential to distinguish between duodenal

contusion, hematoma of the duodenal wall, and

perforation and disruption; the latter are indications for

surgical treatment. If the duodenal injury is associated

with a pancreatic injury, distinguishing individual findings

at imaging can be particularly difficult. Perforation is most

likely to be detected in the descending and horizontal

segments. The differentiation of contusion and bowel

wall hematomas from perforation is vital.

Duodenal perforation is suspected if there is a

retroperitoneal collection of contrast medium,

extraluminal gas, or a lack of continuity of the duodenal

wall. Duodenal contusion is suspected with edema or

hematoma of the duodenal wall, intramural gas

accumulations, and focal duodenal wall thickening (>4

mm) as findings of small bowel injury. Fluid or a

hematoma in the retroperitoneum, stranding of

retroperitoneal fatty tissue, or pancreatic transaction can

be present in both conditions .

(15,17,18,27,28,29,30,31)

A study of 27 children showed that retroperitoneal

extraluminal free air or oral contrast material on CT

images provided a reliable way to differentiate duodenal

perforation from contusions of the duodenal wall.32 In

another study, CT showed that extraluminal contrast

medium was not as beneficial as the presence of free air

in detecting duodenal perforation; extraluminal air on CT

images was present in three of five children with

perforation, but none had extravasation of contrast

material.(26) Most of the contusions of the duodenal wall

and hematomas can be treated conservatively, so

treatment can vary, depending on whether it is a

contusion or a perforation. Mixed attenuation is a sign of

duodenal wall hematoma. However, fluid collections in

the anterior pararenal space only and thickening of the

duodenal wall have been seen in both perforations and

duodenal wall contusions .(27) At present, no specific

data are available about the sensitivity and specificity of

multidetector CT in the diagnosis of duodenal injuries.

Conventional duodenography showed a 54% sensitivity

in the diagnosis of perforation after duodenal trauma if CT

findings were not clear; therefore, it cannot be

recommended as an adjunct to emergency abdominal

CT.(33)

Correct, early diagnosis of pancreatic injuries is

essential for injured patients. Detection of the injury

patterns by using CT depends on a reliable and robust

technique, particularly timing of an emergency CT study

after injury and correct timing of the contrast material

bolus, as well as the experience of the radiologist

involved.(15)

In 20%–40% of the cases studied, initial CT findings of

patients with pancreatic injuries may be within normal

limits in the first 12 hours after the injury; however, much

of the published data is still based on the single-detector

CT technique. CT diagnosis of pancreatic injuries shows

variable sensitivity and specificity because many

findings are subtle, absent, or at times slow to develop.

The sensitivity and specificity of CT in detecting

pancreatic trauma of all grades are reported to be around

80%, and grades of injury tend to be underestimated with

CT.(4,20,23,34,35,36,37) CT findings may be subtle, and

sometimes the pancreas may appear normal. The

integrity of the pancreatic duct is the most important

factor in the decision whether or not to operate. CT is

limited in detection of pancreatic injuries when only little

peripancreatic fat tissue is present and in detection of

88

subtle pancreatic duct injuries.(4,20,34,35,37,38)

Specific signs of pancreatic injuries on CT scans are

fractures or lacerations of the pancreas, edema or

hematoma of the pancreatic parenchyma, active

hemorrhage from the pancreas, and blood collections

between the parenchyma and the splenic vein.(39,40)

The patient in our presentation had no abdominal CT,

mainly because he was hemodinamically unstable, once

he was admitted in our clinic. On the other hand, more

than 90% of all pediatric solid organ trauma can be

managed by conservative means,if the patient is

hemodinamically stable, and does not require a total of

more than 40 ml of blood transfusion/kg body weight in

two administrations. Perforation of a cavitary organ

requires urgent laparatomy.

Another point of discussion is duodenal haematoma.

Intramural haematomas have been reported to occur in

any part of the gastrointestinal tract from the esophagus

to the colon.(41,42,43,44,45) They usually present with

acute abdomen or gastrointestinal obstruction

(41,43,46,47), but are an unusual cause of either of these

presentations. In children, they usually follow accidental

or non-accidental abdominal trauma(47,48) and may be a

rare complication of procedures such as small bowel

biopsy49 or of bleeding disorders such as the

hemophilias or purpuras. Acute abdomen in a child with

hemophilia requires consideration of an intra-abdominal

hemorrhagic complications.

A conservative, expectant management approach in

the form of nasogastric suction and TPN is appropriate in

most patients with intramural bowel hematomas.

(41,43,47)

Resolution can be anticipated to occur in 1-2 weeks,

though this may sometimes be delayed for 1-2

months.(43,47) In a patient with an underlying bleeding

problem, early blood component replacement therapy to

attain and maintain hemostatic levels of deficient factors

is crucial in reducing life-threatening complications from

internal hemorrhage.(50,51) Surgical intervention is

reserved for the few patients with complications such as

perforation, intussusception or persistent obstruction.

(44, 45)

Our patient had a grade III duodenal injury and a

extensive duodeno-jejunal haematoma, which cannot be

managed by conservative means. The importance of

promptly identifying and correcting any underlying lesion

in a abdominal trauma in a known haemophliac is of

major importance, because such high-risk hemorrhagic

events are a cause of acute morbidity and mortality in

haemophilia.

89

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